Acute and Recurrent Bacterial Vaginosis

WHEN BV RECURS
Recurrence rates of 15% to 30% have been reported at three months,^18,19 and of 28% when patients were tested cumulatively over six months,¹ but few researchers have looked at long-term recurrence rates. In one observational study, recurrence rates of 51% were reported during a six-year follow-up period among women previously treated with oral metronidazole.²⁰ Whether these high recurrence rates are due to treatment failure to eradicate the causative organism or to a reinfection from sexual partners remains unclear.²¹ Some studies have shown that treatment of male partners does not affect recurrence rates.^21,22

Risk factors
Various research teams have identified risk factors associated with BV recurrence, but study results have been inconsistent. The strongest risk factor appears to be sexual activity, specifically with increased numbers of sexual partners and inconsistent condom use.^1,23,24 Women who have sex with women also appear to be at increased risk for BV recurrence.^9,10

BV tends to recur around the time of menstruation, and some suppressive therapies include administration of antibiotics during this time.^1,8 Although reports conflict, other risk factors that may be implicated in recurrent BV include vaginal douching, cigarette smoking, and increased BMI.^2,18 Use of an oral contraceptive may have a protective effect against BV recurrence.¹

Caring for patients with multiple recurrences of BV can be challenging for many clinicians. Although a few studies have evaluated suppressive therapy for recurrent BV, there are no clear treatment guidelines for multiple recurrent infections. Sobel and colleagues evaluated twice-weekly use of metronidazole gel for 16 weeks and found a significant reduction in BV recurrence during treatment.²⁵ However, there was only a 34% to 37% probability of patients’ remaining clinically cured at seven months posttreatment. Similarly, Reichman et al evaluated suppressive therapy with oral metronidazole, topical boric acid, and metronidazole gel. They found an 88% to 92% initial cure rate, but a 50% failure rate at 36 weeks’ follow-up.²⁶

Management
Studies examining the use of probiotics for the prevention and treatment of BV have yielded mixed results. The theory is that probiotics containing lactobacillus organisms may protect women from infection by maintaining or restoring vaginal pH and preventing adhesion of bacteria to the epithelium of the vaginal walls.²⁷ Despite the conflicting results, no adverse effects have been reported and, as a consequence, many experts recommend probiotics to reduce the risk for recurrent BV. When discussing suppressive therapy options with patients, clinicians should be mindful of the limited data and the clinically unfavorable long-term cure rates demonstrated.

In addition to treatment limitations for recurrent BV, clinicians often find it challenging to effectively address the psychosocial implications of distress, embarrassment, and lack of control that are commonly associated with recurrent BV.²⁸ Beyond its impact on sexual activity, women have also reported refraining from their daily activities out of fear that others around them may detect their vaginal odor. Helping women take a proactive approach in the treatment and prevention of BV may ease some of this distress.

Women with recurrent BV are often eager to hear about measures they can take to reduce their risk for acute and recurrent infection. Patients should be counseled on the association of BV with douching, numerous sexual partners, unprotected sex, increased psychosocial stress, and cigarette smoking.^7,18,29-31 Patients may inquire about the potential risk for BV when they use feminine hygiene spray, panty liners or pads, and underwear made from synthetic fabrics; however, one longitudinal study³⁰ showed no association between any of these hygienic behaviors and BV.

Continue for the conclusion >>